What next after GDP-based cost-effectiveness thresholds?

Abstract

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage. This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries.

The Use of Cost-Effectiveness Thresholds for Evaluating Health Interventions in Low- and Middle-Income Countries From 2015 to 2020: A Review

“…There is no global CET or consensus on how countries should develop their CET to inform the utilization of public/pooled resources for health (see Appendix 1 in Supplemental Materials found at https://doi.org/10.1016/j.jval.2021.08.014 for information on methods). 4 Ideally, CETs should be contextualized to local health constraints, in particular with regard to available resources or population preferences. For instance, what defines a cost-effective service in the United-States (where public spending on health per capita in 2019 was $9386 5 ) will be very different from what may be cost-effective in Uganda (where public spending on health per capita in 2017 was $24 6 ).…”

Cost-effectiveness of routine adolescent vaccination with an M72/AS01E-like tuberculosis vaccine in South Africa and India

“…Thresholds should be ideally calculated at a country level, and reflect context-specific heterogeneity and disinvestment decisions, however, this is not often possible due to data or analytic constraints. Until recently, it was common for analyses to use 1x or 3x GDP/capita as a threshold in the absence of an empirical estimate, citing the World Health Organization’s Commission of Macroeconomics and Health 25 —yet it was never intended for these figures to be used as cost-effectiveness thresholds, and in practice produced thresholds which were unrealistically high 26 .…”

Modelling the cost-effectiveness of essential and advanced critical care for COVID-19 patients in Kenya

“…The ICER was compared to the Kenya cost-effectiveness threshold estimated by Woods and colleagues(26) (ref) and Ochalek and colleagues (27)which translated to 50% of the country’s GDP per capita (23).…”